type: resource-definitionsresource: CarePlan

CarePlan Definitions

CarePlan

Healthcare plan for patient or group

Definition: Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

Aliases: Care Team

Cardinality: 0..*

Mappings: workflow=Request; rim=Act[classCode=PCPR, moodCode=INT]; w5=clinical.careprovision

CarePlan.identifier

External Ids for this plan

Definition: Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

Comments: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Requirements: Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Request.identifier; w5=FiveWs.identifier; v2=PTH-3; rim=.id

CarePlan.basedOn

Fulfills plan, proposal or order

Definition: A higher-level request resource (i.e. a plan, proposal or order) that is fulfilled in whole or in part by this care plan.

Requirements: Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

Aliases: fulfills

Cardinality: 0..*

Type: Reference(CarePlan, ServiceRequest, RequestOrchestration, NutritionOrder)

Summary: true

Mappings: workflow=Request.basedOn

CarePlan.replaces

CarePlan replaced by this CarePlan

Definition: Completed or terminated care plan whose function is taken by this new care plan.

Comments: The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.

Requirements: Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.

Aliases: supersedes

Cardinality: 0..*

Type: Reference(CarePlan)

Summary: true

Mappings: workflow=Request.replaces

CarePlan.partOf

Part of referenced CarePlan

Definition: A larger care plan of which this particular care plan is a component or step.

Comments: Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed.

Cardinality: 0..*

Type: Reference(CarePlan)

Summary: true

CarePlan.status

Definition: Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

Comments: The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid.

Requirements: Allows clinicians to determine whether the plan is actionable or not.

Cardinality: 1..1

Type: code

Binding: required:request-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Request.status {uses different ValueSet}; w5=FiveWs.status; v2=PTH-5; rim=.statusCode planned = new active = active completed = completed

CarePlan.intent

proposal | plan | order | option | directive

Definition: Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.

Comments: This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. This element is expected to be immutable. E.g. A "proposal" instance should never change to be a "plan" instance or "order" instance. Instead, a new instance 'basedOn' the prior instance should be created with the new 'intent' value.

Requirements: Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

Cardinality: 1..1

Type: code

Binding: required:care-plan-intent

Summary: true

Is Modifier: true (Reason: This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request")

Mappings: workflow=Request.intent

CarePlan.category

Type of plan

Definition: Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.

Comments: There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.addresses.

Requirements: Used for filtering what plan(s) are retrieved and displayed to different types of users.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:care-plan-category

Summary: true

Mappings: w5=FiveWs.class

CarePlan.title

Human-friendly name for the care plan

Definition: Human-friendly name for the care plan.

Cardinality: 0..1

Type: string

Summary: true

CarePlan.description

Summary of nature of plan

Definition: A description of the scope and nature of the plan.

Comments: CarePlan.description is not intended to convey the entire care plan. It is possible to convey the entire care plan narrative using CarePlan.text instead.

Requirements: Provides more detail than conveyed by category.

Cardinality: 0..1

Type: string

Summary: true

Mappings: w5=FiveWs.what[x]

CarePlan.subject

Who the care plan is for

Definition: Identifies the patient or group whose intended care is described by the plan.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: workflow=Request.subject; w5=FiveWs.subject; v2=PID-3; rim=.participation[typeCode=PAT].role[classCode=PAT]

CarePlan.encounter

The Encounter during which this CarePlan was created

Definition: The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.

Comments: This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.

Cardinality: 0..1

Type: Reference(Encounter)

Summary: true

Mappings: workflow=Request.encounter; w5=FiveWs.context; v2=Associated PV1; rim=.

CarePlan.period

Time period plan covers

Definition: Indicates when the plan did (or is intended to) come into effect and end.

Comments: Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

Requirements: Allows tracking what plan(s) are in effect at a particular time.

Aliases: timing

Cardinality: 0..1

Type: Period

Summary: true

Mappings: workflow=Request.occurrence[x]; w5=FiveWs.planned; v2=GOL-7 / GOL-8; rim=.effectiveTime

CarePlan.created

Date record was first recorded

Definition: Represents when this particular CarePlan record was created in the system, which is often a system-generated date.

Aliases: authoredOn

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: workflow=Request.authoredOn; w5=FiveWs.recorded; rim=.participation[typeCode=AUT].time

CarePlan.custodian

Who is the designated responsible party

Definition: When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodian.

Comments: The custodian might or might not be a contributor.

Cardinality: 0..1

Type: Reference(Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)

Summary: true

Mappings: workflow=Request.requester

CarePlan.contributor

Who provided the content of the care plan

Definition: Identifies the individual(s), organization or device who provided the contents of the care plan.

Comments: Collaborative care plans may have multiple contributors.

Cardinality: 0..*

Type: Reference(Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)

Mappings: w5=FiveWs.source

CarePlan.careTeam

Who's involved in plan?

Definition: Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.

Requirements: Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

Cardinality: 0..*

Type: Reference(CareTeam)

Mappings: workflow=Request.performer {similar but does not entail CareTeam}; w5=FiveWs.actor

CarePlan.addresses

Health issues this plan addresses

Definition: Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.

Comments: Use CarePlan.addresses.concept when a code sufficiently describes the concern (e.g. condition, problem, diagnosis, risk). Use CarePlan.addresses.reference when referencing a resource, which allows more information to be conveyed, such as onset date. CarePlan.addresses.concept and CarePlan.addresses.reference are not meant to be duplicative. For a single concern, either CarePlan.addresses.concept or CarePlan.addresses.reference can be used. CarePlan.addresses.concept may be a summary code, or CarePlan.addresses.reference may be used to reference a very precise definition of the concern using Condition. Both CarePlan.addresses.concept and CarePlan.addresses.reference can be used if they are describing different concerns for the care plan.

Requirements: The element can identify risks addressed by the plan as well as concerns. Also scopes plans - multiple plans may exist addressing different concerns.

Cardinality: 0..*

Type: CodeableReference

Binding: example:clinical-findings

Summary: true

Mappings: workflow=Request.reason; w5=FiveWs.why[x]; v2=PRB-4; rim=.actRelationship[typeCode=SUBJ].target[classCode=CONC, moodCode=EVN]

CarePlan.supportingInfo

Information considered as part of plan

Definition: Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc.

Comments: Use "concern" to identify specific conditions addressed by the care plan. supportingInfo can be used to convey one or more Advance Directives or Medical Treatment Consent Directives by referencing Consent or any other request resource with intent = directive.

Requirements: Identifies barriers and other considerations associated with the care plan.

Cardinality: 0..*

Type: Reference(Resource)

Mappings: workflow=Request.supportingInfo

CarePlan.goal

Desired outcome of plan

Definition: Describes the intended objective(s) of carrying out the care plan.

Comments: Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

Requirements: Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

Cardinality: 0..*

Type: Reference(Goal)

Mappings: v2=GOL-1; rim=.outboundRelationship[typeCode<=OBJ].

CarePlan.activity

Action to occur or has occurred as part of plan

Definition: Identifies an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, education etc.

Requirements: Allows systems to prompt for performance of planned activities, and validate plans against best practice.

Cardinality: 0..*

Type: BackboneElement

Mappings: workflow={no mapping NOTE: This is a list of contained Request-Event tuples!}; rim=.outboundRelationship[typeCode=COMP].target

CarePlan.activity.performedActivity

Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)

Definition: Identifies the activity that was performed. For example, an activity could be patient education, exercise, or a medication administration. The reference to an "event" resource, such as Procedure or Encounter or Observation, represents the activity that was performed. The requested activity can be conveyed using the CarePlan.activity.plannedActivityReference (a reference to a “request” resource).

Comments: The activity performed is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to exercise, then the activity performed could be amount and intensity of exercise performed whereas the goal outcome is an observation for the actual body weight measured.

Requirements: Links plan to resulting actions.

Cardinality: 0..*

Type: CodeableReference

Binding: example:care-plan-activity-performed

Mappings: workflow={Event that is outcome of Request in activity.plannedActivityReference}; rim=.inboundRelationship[typeCode=FLFS].source

CarePlan.activity.progress

Comments about the activity status/progress

Definition: Notes about the adherence/status/progress of the activity.

Comments: This element should NOT be used to describe the activity to be performed - that occurs within the resource pointed to by CarePlan.activity.plannedActivityReference.

Requirements: Can be used to capture information about adherence, progress, concerns, etc.

Cardinality: 0..*

Type: Annotation

Mappings: v2=NTE?; rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value

CarePlan.activity.plannedActivityReference

Activity that is intended to be part of the care plan

Definition: The details of the proposed activity represented in a specific resource.

Comments: Standard extension exists ([[[http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal]]]) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.plannedActivityReference.
The goal should be visible when the resource referenced by CarePlan.activity.plannedActivityReference is viewed independently from the CarePlan. Requests that are pointed to by a CarePlan using this element should not point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.

Requirements: Details in a form consistent with other applications and contexts of use.

Cardinality: 0..1

Type: Reference(Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestOrchestration)

Mappings: workflow={Request that resulted in Event in activity.performedActivity}; rim=.outboundRelationship[typeCode=COMP].target

CarePlan.note

Comments about the plan

Definition: General notes about the care plan not covered elsewhere.

Requirements: Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.

Cardinality: 0..*

Type: Annotation

Mappings: workflow=Request.note; v2=NTE?; rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value